Abortion after Roe

Johanna Schoen

• Publisher: The University of North Carolina Press
• Year: 2015
• Print ISBN: 9781469636016, 9781469621180
• eBook ISBN: 9781469621197
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

Abortion is — and always has been — an arena for contesting power relations between women and men. When in 1973 the Supreme Court made the procedure legal throughout the United States, it seemed that women were at last able to make decisions about their own bodies. In the four decades that followed, however, abortion became ever more politicized and stigmatized. Abortion after Roe chronicles and analyzes what the new legal status and changing political environment have meant for abortion providers and their patients. Johanna Schoen sheds light on the little-studied experience of performing and receiving abortion care from the 1970s — a period of optimism — to the rise of the antiabortion movement and the escalation of antiabortion tactics in the 1980s to the 1990s and beyond, when violent attacks on clinics and abortion providers led to a new articulation of abortion care as moral work. As Schoen demonstrates, more than four decades after the legalization of abortion, the abortion provider community has powerfully asserted that abortion care is a moral good.

Chapter 1: Living through Some Giant Change

The Establishment of Abortion Services

On January 22, 1973, the United States Supreme Court legalized abortion in its decision Roe v. Wade. Minutes after the news was broadcast, Susan Hill, then a twenty-four-year-old social worker in Miami, Florida, received a call from physician Sam Barr. Would she like to join him in opening an abortion clinic, Barr inquired. Two weeks later, the new clinic opened its doors to hundreds of women seeking legal abortions from all across the southeastern United States. Across the country, a group of feminists in Iowa City, Iowa, who had previously referred women to underground abortion providers, picked up the phone to call local physicians and ask when they were going to start offering abortion services and how much an abortion would cost. “They virtually hung up on us,” one of them remembered. “I mean they were just incensed that we had called because they had no intention of changing what it was they were doing.”¹ Frustrated with the response of Iowa City physicians and inspired by the court victory and the growing women’s self-help movement, they decided to form a feminist collective and open their own clinic. And in Highland Park, Michigan, twenty-one-year-old office assistant Renee Chelian began to schedule abortion patients for Dr. Gilbert Higuera. Prior to the Roe v. Wade decision, Chelian and Higuera had flown every weekend to Buffalo, New York, where abortion had been legal since 1970. There, they had provided abortion services out of a small office. Now Higuera closed his Buffalo clinic and moved all its equipment into his regular ob-gyn office outside Detroit. “For me, everything changed,” Chelian remembered. “All of a sudden, I had a dream about what I thought things should be like.”²

With the legalization of abortion and the simultaneous introduction of medical equipment to perform first trimester abortions with vacuum aspiration machines, a previously clandestine and dangerous procedure became safe, quick, and inexpensive almost overnight. As Americans witnessed the emergence of a growing network of abortion clinics, abortions that had previously been invisible, performed secretly by underground providers or behind the curtains of private physicians’ offices, became visible. The number of legal abortions climbed from 744,610 in 1973 to over a million in 1975, while the estimated number of illegal abortions declined. This development had a dramatic impact on abortion mortality. While the mortality rate due to abortion hovered between 60 and 80 deaths per 100,000 cases in the decades prior to legalization, it sank to 1.3 by 1976–77. Legal abortions before sixteen weeks’ gestation, the authors of a study on morbidity and mortality of abortion concluded, had become safer than any other alternative available to the pregnant woman, including continued pregnancy and childbirth.³

Physicians and women came to the field of abortion care with disturbing memories of illegal abortions. Many physicians interested in providing abortions had cared for women suffering from the complications of illegal abortion and had seen their patients die. Now they hoped to establish services that offered safe and affordable abortions to all women. And many of the women who found their way into the emerging field of legal abortion care in the early 1970s had themselves experienced an illegal abortion, participated in underground abortion services while abortion was illegal, referred others to those services, or had friends or relatives with such experiences. Inspired by the emerging women’s movement and frustrated with traditional medical care, which they viewed as patriarchal and paternalistic, they looked to the field of abortion care as an opportunity to shape a more feminist future in medicine. Both groups came together in the early 1970s to establish a new system of abortion care. At times uneasy allies—male physicians found young feminist women challenging and demanding while young women found male physicians patronizing and dismissive of their concerns—they nevertheless negotiated over different aspects of abortion care and established a broad network of abortion clinics which influence abortion services to this very day.⁴

Their efforts were also influenced and moderated by other interests, however. The high demand for and scarcity of abortion providers meant that the establishment of abortion services promised to be extremely lucrative. While the establishment of feminist health services could mean good business, a focus on profits could also drive prices up and the quality of services down. Tugged on the one side by a demand for profits and on the other by feminist critiques of the commodification of abortion services and calls to put women’s experience at the center of care, abortion providers established a broad range of services from clinics founded as profit-making endeavors to feminist health collectives. Where the clinics fell along this spectrum depended, however, less on the attitude toward profits and more on the influence of individuals associated with the emerging abortion clinics.

But the provision of abortion care met resistance from early on. Most physicians were not interested in providing legal abortions. Hospitals imposed limits on the number of legal abortions physicians could perform. Cities and townships turned to local ordinances, building codes and zoning restrictions to prevent the opening of abortion clinics. The successful establishment of abortion services required complicated negotiations with physicians, hospital administrators, public health officials, and local politicians. The ability to overcome legal and institutional obstacles varied by time and place and contributed to the uneven distribution of abortion services for years to come.

A Simple Mechanical Procedure: The Development of Pregnancy Termination Procedures

The legalization of abortion opened what had been a covert surgical procedure to the scrutiny of medical professionals and the lay public alike. If the illegal or only quasi-legal nature of abortion had previously stifled research on the topic, legalization opened the procedure to scientific inquiry and debate. Virtually overnight, abortion became one of the most studied procedures in the United States. Some physicians and journalists had spoken and written about abortion long before the procedure became legal, discussing methods, estimating morbidity and mortality rates, and arguing for legalization.⁵ But now they began to systematically collect data on pregnancy termination procedures and to publish the results in medical journals across the country. The ability to collect and compare data in turn fostered the development and introduction of new procedures and quickly contributed to the refinement of physicians’ techniques. While the systematic persecution of illegal abortionists in the 1950s and 1960s had driven abortion underground and turned it into a risky or even deadly procedure for most women, legalization made abortion into the safest and most widely performed surgical procedure in the United States.⁶

Physicians’ perception of abortion procedures was shaped powerfully by their experience with illegal abortion. As historian Leslie J. Reagan’s research has shown, in the decades just prior to Roe v. Wade, abortion providers were increasingly prosecuted, and fewer physicians were willing to perform abortions than in the 1930s and 1940s. While physicians in larger hospital settings might occasionally terminate a pregnancy, such procedures required complicated approval by hospital abortion committees. Some women might qualify for a so-called therapeutic abortion if a physician found that pregnancy and delivery seriously impaired a woman’s health or endangered her life. But such approvals were rare. A 1944 article presenting a table showing the incidence of therapeutic abortion compared with the number of deliveries at seven hospitals noted that Johns Hopkins University topped the list, with a therapeutic abortion to delivery ratio of 1:35, whereas Margaret Hague Hospital in New Jersey had the lowest ratio of 1:16,750.⁷ As a result, more women were forced to turn to underground abortion providers, leading to an increase in the number of women who entered hospital emergency rooms with complications from illegal abortions.

For a whole generation of physicians who entered medical school and internships in the postwar era, the experience of abortion was tied to memories of caring for women with abortion complications. Those memories were frequently frightening. Physicians recall their despair trying to save women’s lives before they bled to death or died of overwhelming infections. “We had a ward of patients who we admitted during the weekend,” one physician remembers of his time as an ob-gyn intern and resident. “You’d go up there and it would smell. They’d have a tomato soup discharge. I remember one patient and as fast as we’d put the blood in, it would run and fill up your shoes.”⁸ In addition, many physicians had been frustrated with a system in which women with money and connections could obtain a dilation and curettage (D&C) abortion—in which the cervix is dilated and the contents of the uterus scraped with a curette—from their private physicians, while women without such resources ended up in the emergency room with complications from illegal procedures. “The poor pulled the innards out or got soap shot up inside them,” a St. Louis physician commented.⁹ In some urban public hospitals, entire wards were reserved to care for patients admitted after illegal abortions had gone bad. On any given afternoon during the 1950s and early 1960s, for instance, Los Angeles County Hospital cared for 50 to 100 women who had obtained illegal abortions.¹⁰ Every one of these hospital wards was staffed by residents and physicians who were profoundly influenced by their experiences with these patients. Their concern with women’s health and safety drove the discussion and development of pregnancy termination procedures.

The very ease and speed with which patients gained access to abortions after legalization is tied to the invention of a procedure called vacuum aspiration. Prior to the introduction of this procedure, physicians seeking to terminate a pregnancy performed a D&C, which was relatively unpleasant to perform. As one physician recalls: “Doing an abortion by routine D&C was … a very bloody procedure. Frighteningly so, sometimes.… I don’t think that without the advent of suction abortion that abortion would ever have been as accepted by the medical practice as it was … and not because you were interrupting a normal pregnancy, that wasn’t it.… It was strictly the risks.”¹¹ The risks included perforation of the uterus, hemorrhage, and infection. Vacuum aspiration, in which, as the name suggests, the contents of the uterus are sucked out by a vacuum aspiration machine, not only was quicker than performing a traditional D&C but also was safer, was more likely to result in the complete removal of all tissue, led to less blood loss and fewer major complications, and was more adaptable to local anesthesia.¹²

The development of vacuum aspiration was an international endeavor, taking place simultaneously in several places across the globe. Its early history dates back to 1860, when Sir James Young Simpson of Edinburgh pioneered the use of syringe suction inside the uterine cavity. In 1927, S. G. Bykov of Russia used a syringe to bring on menstruation. The modern development of suction curettage can be traced to three Chinese physicians who, in 1958, reported on vacuum aspiration in the Chinese Journal of Obstetrics and Gynecology. In 1960, Dr. E. Melks, a Soviet physician in collaboration with a Soviet engineer, designed an apparatus that they called the vacuum excochleator. The machine featured metal curettes with an opening at the tip which drew in the fetal material and a mechanical crusher driven by an electric motor to crush larger fetal parts. In 1963, at the 11th All Union Congress of Gynecologists in Moscow, Dr. E. Melks reported performing a large number of vacuum aspiration cases, and shortly thereafter, vacuum aspiration spread to Eastern Europe and Japan.¹³

The first two articles on the subject in the American literature appeared in the July 1967 issue of Obstetrics and Gynecology in which Drs. M. Vojta and Dorothea Kerslake discussed therapeutic abortion by vacuum aspiration in Czechoslovakia and England, respectively.¹⁴ American physicians took note, and in 1968 the Association for the Study of Abortion, one of the first medical abortion rights groups, organized a conference on abortion in Hot Springs, Virginia, featuring a presentation by the Yugoslav Franc Novak in which he introduced American physicians to vacuum aspiration. Novak marveled at the ease of vacuum aspiration. “When the gynecologist who knows only the conventional D and C first sees the apparatus in action, he is impressed by the cleanness, apparent bloodlessness, speed, and simplicity of the operation. While a D and C gives the impression of a rude artisan’s work, an abortion performed with suction gives the impression of a simple mechanical procedure.”¹⁵

Immediately after the reform of North Carolina’s abortion law in 1967, Jaroslav Hulka, an associate professor at the UNC School of Public Health and the Department of Obstetrics and Gynecology, traveled to Newcastle upon Tyne to observe Dr. Kerslake’s procedure. Hulka had already seen a motion picture about the procedure that Kerslake had made. “I went and visited her to see if I could learn anything more. So, I bought the equipment that she had and that was the first equipment being used.”¹⁶ Together with his colleague Dr. Takey Crist, Hulka started performing vacuum aspirations at North Carolina Memorial Hospital. While their unfamiliarity with the equipment initially led to a high complication rate, they quickly learned how to use the machine properly, and their success convinced colleagues to adopt the new technique as well. “And, of course, he [Takey Crist] got into trouble and I got into trouble—I mean medical trouble, complications. We were doing abortions and we didn’t really know how to do them and it was difficult at first. But then eventually it got ironed out and as they [their colleagues] saw that these two cowboys were actually doing this procedure, gradually more and more people wanted to learn how to do it. So, people learned eventually, went out and did it.”¹⁷

The first suction machines were crude instruments (see ill. 1.1) that were noisy and even dangerous. It was impossible to measure the vacuum pressure, and some of the earliest equipment simply u...

Table of contents

• Cover Page
• Abortion after Roe
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Abbreviations and Acronyms
• Introduction
• Chapter 1: Living through Some Giant Change
• Chapter 2: Medicine at the Edges of Life
• Chapter 3: The Formation of the National Abortion Federation and the Standards Debate
• Chapter 4: The Development of Dilation and Evacuation and the Debate over Fetal Bodies
• Chapter 5: To Protect the Lives of American Babies
• Chapter 6: Truths, Lies, and Partial Truths
• Epilogue
• Notes
• Bibliography
• Index